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12/31/2003 10:53 7074466 CAL -INC PAGE 02 <br />1 1 is <br />A. <br />SAN JOAQUIN COUNTY E.IYVMON NTALI TJJP Tf NT <br />SERVICE REQ[JET'''I?`:;''�r <br />Type of Business or Property <br />' <br />FSERVICE <br />0 `fib ' <br />AM I I; <br />REQUEST # <br />3 t;: <br />a <br />OWNER OPERATOR � <br />�(va %1 �0 GC• 1f i T\ �(� � +�� C. ��ai [�-� <br />CHECK if BILLING Anome <br />FacluTrNAME ��� Suc,ctiU�r. ��� <br />��na.C,� �13�'0•� �oo� <br />SITE ADDRESS <br />SIC66t Number <br />Di on <br />C12,1 <br />E4 net Nano <br />V 1 G' <br />t Cada <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />STATE C /� <br />Strook Nnmo <br />CITY <br />EMPLOYEE iI: , . <br />STATE zip <br />PHONE41 EXT. <br />LA 6'I <br />( 1 � <br />APN #LAND <br />'I�' 1 �t75:J�l <br />USE APPLICATION # <br />�►a� <br />PHONE #2 Exr. <br />SeRMLCOM. <br />6G3 (}tt4TFdr <br />Lacprlora GaoE <br />CONTRACTOR /SERVICE REQUESTOR <br />REQt1EST0R <br />' <br />CHECK If BILLING ADDRE88 <br />BUSINESS NAMEPHONE <br />cf�� <br />i) <br />Exr' <br />.INS <br />DEC 312003 <br />701 <br />Homi=- or WuNG ADDRESS <br />FAx#1 <br />(-701 ) <br />ENVIRONMENTAL <br />CITY �IG.0 l�� <br />STATE C /� <br />cL <br />ZIP q5 b P� <br />RIMING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRO.NimveA1.14EAL1'i-i DBPA1tuI zxr hourly charges associated with this project <br />or activity will be billed to me or my business as identified on this form <br />I also certify that I have prepared this application and that the York to be performed will be done in accordance with all SAN JoAQUIN <br />COUNTY Ordinance Codes, Standards, STATE FEr)ERAL laws. <br />.AP PUCANT'S SIGNATIM: DATE: /a'2/3100 3 <br />]PROPERTY f BUSINESS OWNER 0 O 1zATORII►IAN GER 0 OTHER AITTHOR17XI)A,CFMrd,0 6 <br />If APPLICANT' is no t the firl.CVVG Pr4tt7T' proof of authorizadon to sign is required <br />,A_UtTI€ DEJZATION TO RFLFASL+ INFORMATION: When applicable, I, the owner or operator of the property located atbe <br />above site address, hereby authorize the release of any and sit results, geotechnical data and/or environmental/site assessment <br />information to the SAN JOAQTmN COON-rY EN vmOV_vi)_=NTAL Eh ALTH DEPARTMENT' as soon as it is available and at the same time it is <br />provided to me or my repr smtative. <br />TYPE OF SERVICE REQUESTED: <br />' <br />RECEIVED <br />COMMENTS: <br />DEC 312003 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />At490VED QY: <br />RidENWLOWE <br />EMPLOYEE iI: , . <br />DATE; 3L <br />AsB[arieDta: <br />:. <br />3 <br />DATE <br />?/W <br />Dbtt . ServIce Completed (df already ooinpleted): <br />SeRMLCOM. <br />PIE. <br />1Fge Amount: <br />Amount PAMPaylne <br />Rate ! 3; �✓' <br />Paynnorlt TypeMrtvoicl� <br />#t <br />+~hlecli.#' �, �L <br />Received By: <br />END 48-01-025 SERVICE REQUEST FORM <br />REVISED 6-5-02 <br />